Medicare beneficiaries know that having access to affordable medications is critical for maintaining their health and well-being. Medicare Part D does not always make it easy to understand which medications are covered and which are not. One issue is coverage limitations for certain medications. Fortunately, there are ways to request exceptions to these limitations and ensure that you have access to the medications you need.
Tier Exceptions: Medicare Part D drug plans have different “tiers” of coverage. If your medication is not on the preferred tier, you may have to pay a higher cost-sharing amount. However, you can request a Tier Exception to get a lower cost for a specific medication.
Formulary Exceptions: The formulary is the list of medications that your Medicare Part D plan covers. If your medication is not on the formulary, you may have to pay the full cost. However, you can request a Formulary Exception to get coverage for a specific medication.
Medicare Part D plans may also have restrictions on Step Therapy, Quantity Limits, and Dosage Limits. Step Therapy requires you to try less expensive medications before trying more expensive ones, while Quantity Limits and Dosage Limits limit the amount of medication you can receive. However, you can request exceptions to these limitations if you and your doctor believe that they are not appropriate for your health needs. To request exceptions, you or your doctor can submit a form to your Medicare Part D plan. You’ll need to provide information about your medical condition and why the requested exception is necessary. Your Medicare Part D plan will review your request and let you know if it has been approved or denied within 72 hours.